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GYN
CMECNE

Office Evaluation of Breast Disorders

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Summarize the role of ultrasound and mammogram in evaluation of a palpable mass
2. Recall what BI-RADS level should prompt a biopsy

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

While multiple disciplines are required to diagnose and manage both benign breast disorders and breast cancer, the most important interaction with a patient remains the initial office visit

  • Obtain careful history of all breast related symptoms including duration, changes in symptoms over time, presence and color of nipple discharge
  • Identify risk factors for breast cancer, including
    • Advanced age (over 65)
    • Positive family history
    • Age >30 at first birth
    • Nulliparity
    • Never breastfed
    • Menopausal hormone therapy
    • Alcohol use (not clear what the threshold is)
  • Visually inspect and manually palpate the breasts, axillae and supraclavicular nodal regions
  • Clinical documentation of any mass should include size, consistency, distance from areola and clock position in the breast
  • Diagnostic imaging includes ultrasonography, mammogram or digital tomosynthesis
    • Manage breast lesion based on age, clinical suspicion, Breast Imaging Reporting and Data System (BI-RADS) and other imaging findings
    • Ultrasound can differentiate solid from cystic lesions
  • Histology can be obtained from fine needle aspiration (FNA), core needle biopsy or excisional biopsy, procedures that are usually performed by radiologists or surgeons
  • Women ≥30 years and older with palpable mass
    • Mammogram followed by ultrasound, if necessary
  • Women under 30 years with a palpable mass: Ultrasound is the primary imaging modality
    • If ultrasound imaging is suspicious for cancer, follow up with tissue biopsy
    • If ultrasound does not suggest malignancy but clinical suspicion remains, perform a diagnostic mammogram
    • If ultrasound imaging suggests a benign cyst or a benign appearing solid mass options are to follow-up with physical exam +/- ultrasound/diagnostic mammogram every 6-12 months for 1-2 years to assess stability
  • Women presenting due to a mass that cannot be palpated by patient or clinician should not be dismissed and must be followed up with imaging

SYNOPSIS:

Benign breast lesions can be categorized as nonproliferative (breast cysts), proliferative without atypia (fibroadenoma, intraductal papilloma, fibrocystic change) which may carry a small risk (1.5 to 2 times above general population) for breast cancer and atypical hyperplasia (ductal or lobular). The latter category carries a substantially increased risk of subsequent invasive cancer in either breast (see ‘Related ObG Topics’, below). Nipple discharge is common, and usually benign. Unilateral, uniductal and spontaneous discharge carries a higher risk of malignancy and should be further evaluated with ultrasound.

KEY POINTS:

  • Women ≥30 years with palpable breast masses shown to be solid on imaging should be biopsied if BI-RADS 4-5, or if BI-RADS 1-3 with high clinical suspicion
    • Observation an option if BI-RADS 1-3 and low clinical suspicion (see ‘Related ObG Topics’ below)
  • Women with simple cysts can undergo routine follow-up
    • Consideration for biopsy should be given to complicated cysts with BI-RADS 1-3
    • Complex cysts with BI-RADS 4-5 on imaging require biopsy
  • When common skin problems are identified in the breast such as psoriasis, eczema, contact dermatitis, Candida infections, standard treatment should be used
  • Skin edema, warmth and erythema as well as ulceration, nipple retraction/crusting/scaling should raise concerns for malignancy and require tissue diagnosis
  • ICD-10 CM Code N63 (breast lump)

Learn More – Primary Sources:

ACOG Practice Bulletin No 164: Diagnosis and Management of Benign Breast Disorders

ACS: Breast Cancer Prevention and Early Detection

Benign Breast Disease in Women

Common Breast Problems

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Related ObG Topics:

Mammography Guidelines for Average-Risk Women
BI-RADS: Standardizing Breast Imaging and Reporting 
Atypical Hyperplasia of the Breast: Follow up and Management
USPSTF Guidance: When to Use Medication to Reduce Breast Cancer Risk
Obstetrics Critical Care Course

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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